Provider Demographics
NPI:1225537525
Name:DISTEFANO, DOUGLAS LOGAN (DPT)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:LOGAN
Last Name:DISTEFANO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 BAYSHORE DR APT B
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71901-9630
Mailing Address - Country:US
Mailing Address - Phone:318-792-7987
Mailing Address - Fax:
Practice Address - Street 1:100 CALELLA RD STE 100
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS VILLAGE
Practice Address - State:AR
Practice Address - Zip Code:71909-3174
Practice Address - Country:US
Practice Address - Phone:501-984-2453
Practice Address - Fax:501-525-1773
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-02
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1300819225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1300819OtherTEXAS BOARD OF PHYSICAL THERAPY EXAMINERS